(Almost) everything you need to know about infertility but didn't know to ask

November 26, 2007

November 20, 2007

Back in July, when I first started dabbling with the idea of a blog, I didn't have a good grasp of the enormous potential of this medium. While I am grateful to TypePad for hosting this blog and providing a easy-to-use platform for a beginner like me, it's now time to move up to a format that gives me more flexibility and options. Starting in a few weeks, the new Fertility File site will be self hosted on it's own server!

One of the side effects of the increasing popularity of this site was that patients were finding the blog and then following the links to my private practice website and then coming to me as a patient. While I was glad to have met those patients, especially the ones who are now already pregnant, I've decided to distance the blog from my personal practice in the sense that I don't wish to have the blog perceived as a vehicle to steer traffic to my practice (not that there is anything inherently wrong with that). Still, I've removed the main links to my practice and to my own identity that were originally on this site.

Sure, I realize it wouldn't take a diligent google detective too long to find me, but at least this no longer runs any risk of looking like blatant commercial promotion. This affords me more journalistic freedom to say what's on my mind, without looking like I'm using the blog to drum up business, of which I presently don't have any shortage. The further good news is that I look forward to building up this site and providing more entertaining, useful information. Now those of you who are already my patients or who have already found my practice through other means are still welcome to gain benefit from this blog.

Please take a moment to take this brief survey and help shape the future of this site. Thanks and happy Thanksgiving. I have a lot to give thanks for!

November 14, 2007

Hello, I am very confused, and maybe you can help. Here is my story, it is
short compared to most but still no one seems to agree on the problem. I
delivered a healthy baby girl in 2004 at age 26. At 29, I got pregnant again in
March, but lost the baby in April. Both times I got pregnant immediately, the
first month of trying. I have now been trying again for 6 months. I have regular
periods, like clockwork, grab a pad in the morning before I even start kinda
regular (29-30days). They did a vaginal ultra sound to check on a small, tiny
fibroid i have, there are no more, and it is small... too small to cause
problems. At this time the meanie, yucky, ultra sound lady tells me my ovaries
are the size of a post menopausal women, and that I most likely have POF, and to
start thinking about adoption. I thought I would puke on the table. Now, they
are wanting me to go through a battery of tests, calling this "being aggressive"
and have ordered all the bloodwork and even the HSG. Now, I am only 30 years
old, and everything I've read about POF presents with missed periods... Anyway,
my question is, do you think these tests are necessary? Does it matter in the
least that I have regular periods? Or that I got pregnant on my own 6 months
ago? Why is everyone talking about "being aggressive"?-Tara in KS

Dear Tara, I don't know your entire story of course, but based on what you provide, I would agree that your instincts are correct that there may be some overreaction here. If I read you correctly, you are 30, got pregnant very easily and delivered a healthy girl. Then you got pregnant again immediately upon trying at age 29, but sadly, lost the pregnancy in the first trimester. Now, it had been six months and no pregnancy. Based on this information alone, it would be hard-pressed to say that you have any problem at all. There's nothing abnormal about having one miscarriage. There is nothing abnormal about six months passing without getting pregnant. Again, according to your email, your doctors are telling you that they are very concerned because your ovaries are small on ultrasound. You don't provide any measurements saying just how small they are, but still, if you got pregnant on your own six months ago and are having regular periods, I don't see the need yet to get "aggressive". The blood test you are talking about is probably a FSH level. That's not an unreasonable thing to get because it's inexpensive and easy to do. The HSG, on the other hand, is more expensive and invasive. It also puzzles me why they would get an HSG to address a suspicion of POF. POF is an ovarian problem. HSG's give information about the uterus and tubes, not the ovaries. In any case, my best advice is to have a quality discussion with your doctors. They might have some additional information that you are not providing here. I really hope you get pregnant on your own again, and soon. Good luck!!

November 10, 2007

Four months ago, I was just a doctor who loved his work. Two months ago, I was a doctor and a newbie blogger. Today? Well, that's still what I am today, for now anyway. I just finished attending the 2007 BLOGWORLD Expo in Vegas where I rubbed shoulders with some of the greatest bloggers in the world. Here were people, all with very different stories, but who shared one thing in common, a great love and ability for sharing their thoughts and emotions with their captive audiences throughout the internet world. The meeting ended with a stirring talk by Mark Cuban, passionately sharing his experience with his own blog. It was a humbling experience for me, and I loved it!

For years, I've been on the other side of the lectern, giving talks and sharing my knowledge and expertise on infertility with hundreds of doctors and medical students in my position as a faculty member of a medical school (now of TWO medical schools as of earlier this year). I also had gotten into the habit of doing a fair amount of informal teaching, complete with handouts and diagrams, to my own patients during their day-to-day care. So here I was at the Expo, no longer the teacher, now the newbie student, absorbing an overwhelming amount of information in a field I previously knew little about, realizing with excitement that there was a whole new world for me to explore.

So for now, I will keep on learning and improving this site for you. I love your feedback, so keep it coming!

November 04, 2007

One of the most common questions women ask themselves when they are trying to conceive is "Could I be pregnant?" It's very normal and common to become a little obsessed with this without your even realizing it. This question usually pops into your mind during the time between when you have ovulated and the time when you expect your next period to come (or hopefully, NOT to come). For those of you undergoing fertility treatment, it is especially strong and starts to occur after your insemination or your embryo transfer.

Bear in mind that during the times in your life when you were NOT yet trying to conceive, you have had different feelings on different days. Some days, you might be more tired than others. Some days, you might get a headache or momentarily feel a rumbling in your stomach. You might have soreness in your breasts on occasion. All these things go unnoticed. However, when you are focused on conceiving, it is normal for you to pay meticulous attention to each little change. Your mind will start to play tricks on you and you will associate every little change with the possiblity of pregnancy. "Does the fact that my back aches mean that I'm feeling implantation?" "Does the increase in my appetite despite my feeling a little bloated mean I'm pregnant?" "I can't describe it but something just feels a little different these past few days, maybe it means I'm pregnant?"

When my patients undergo fertility treatment and come in on the big day when they get their blood drawn to see if they're pregnant or not, I often get to inquire how they're feeling. They are a little nervous that day, of course. Sometimes, however, they will share some additional information about some new thing they're feeling, such as being very tired or very hungry or a little nauseous or urinating a lot or noticing breast swelling or feeling like their face is glowing or having strange cramping. They often volunteer a guess as to whether their test will come back positive or not. I always tell them that we'll have their result back in an hour once we run their blood through our machine and only then can we know for sure.

From years of this, I am convinced that very few women are truly able to predict with 100% accuracy if they're pregnant or not. There was this one patient who has three babies with us in her life. She required a total of seven insemination treatments to have her three successes. The first two cycles were unsuccessful, while the third resulted in her first son. A year later, the fourth cycle resulted in her second son. A few years later, she came back and failed cycles #5 and #6 before getting pregnant on cycle #7 with her third child, a daughter. Each time, when getting her blood drawn she would either look dejected and say, "I know I'm not pregnant" OR she would beam with joy and say "I know it worked this time". Each of the seven times, she was correct! My staff would marvel at her uncanny ability and we joked that we shouldn't even bother doing her tests.

However, there have been other times when patients came in for their blood test with shining optimism that they knew they were pregnant, but when the results came off the machine, it turned out they weren't. More commonly, there are patients who come in and sadly share that they have already had a little bleeding and they feel that their period is coming, so why even bother testing. Many many times, the tests are positive and the patients go on to have a healthy baby! My point is that pregnancy tests are the best way to accurately know if someone is pregnant or not. All the little symptoms you notice may or may not mean something.

By the way, when I questioned that one patient what symptoms enabled her to predict so accurately all the times she was pregnant, she burst out laughing and confessed, "Doctor, I cheated! I always do a home pregnancy test in the morning before I come in for my blood test."

October 31, 2007

My staff and I love it when patients send us pictures of their babies. It is a happy reminder that the eggs, sperm and embryos that we see everyday grow up to be very real adorable little people. One of my favorite patients sent me these darling photos of her little girl in a pumpkin patch. Such creativity really stands out amidst all the hundreds of other pictures taken at the Sears studio. But we love those too!

These two pictures especially cheered me up just when I was starting to get a little disillusioned with Halloween lately. I recall how during my younger days in Indiana, we used to fearlessly go trick-or-treating by ourselves, unaccompanied by parents. It was such a time of carefree childhood fun. I'm not sure if those times were safer or if we were just more naive. Our biggest worry at the time was that some bully would steal our bags of candy. I remember one year going out dressed as a little surgeon (no I didn't have the foresight to be a little reproductive endocrinologist). After my younger sister had finished collecting a large pillowcase full of candy, a delinquent gang of high school boys sped by on their bikes and did a drive-by snatching of all her hard work for the night. What I find most memorable about that night came afterwards, when we went back to the same houses with my sister in tears. When the candy-givers learned what had happened, their hearts opened up and they started giving her all their extra candy, even going back to the kitchen to get the "good stuff". That year, my sister wound up with ten times the candy that she usually got.

Nowadays, besides being just a reminder of how unsafe the world has become for children, Halloween seems to have grown into just another opportunity for girls to dress provocatively in public. I've attended a few parties these past few years where I noticed the recurring theme of girls dressed in actual lingerie, but then adding a pair of large wings so they could turn it into some sort of "slutty angel" outfit. Times have changed.

Still, I know that my cynical Halloween comments won't even faze those of you with kids one bit as you witness their little smiles today. As for those of you who are yet to have kids yet, this is why we in the fertility field work so hard doing what we do, so that hopefully, everyone who wants to be a parent will get their chance. Have a safe and happy Halloween, everyone. =)

October 28, 2007

When you spend money to do infertility treatment, you trade your hard-earned resources to get a boost towards getting pregnant sooner. How would you feel about spending money to LOWER your chances? This is exactly what happens when you or your partner smokes.

I usually start off by telling my smoker patients that cigarette smoke, whether actively inhaled or even breathed passively, can harm the ability to conceive. Consider the fact that the tars, ammonia, hydrogen cyanide, fomaldehyde and carbon monoxide found in smoke are toxins that can cause short-term damage to eggs and sperm as well as accelerate the aging process so as to cause long-term damage in females. Toxins are concentrated in the cervical mucus of the female, rendering a hazardous barrier to the sperm as they try and swim past.

Smoking may not just hurt your chance to conceive naturally. It can also lower your odds of success with IUI or IVF, requiring more cycles and more time to achieve the pregnancy you want. Smoking during pregnancy can cause an increase in obstetric complications and even affect the child after birth, including a higher risk of sudden infant death syndrome

BUT, as much as I look negatively on the effects of smoking, I am not in favor of demanding government bans on smoking. I believe in the principle of individual freedom, which includes the rights of smokers to harm their own health as long as the rights of non-smokers are not infringed upon. These include the right not to be exposed to second-hand smoke and the right not to be financially burdened to care for the excess health problems brought on by smoking. In any case, I continue to do my part to offer education to others to help them make their own decisions.

Please remember that the decisions that you make will affect how long it takes before you have a healthy baby.

October 24, 2007

Karen was 34-years-old and very successful in her career when she first consulted several years ago. One day, after watching a CBS 60 Minutes special on the biological clock in women, she had an awakening. She realized two things. One was that she was getting older, with no man in her life, and two, she was very sure that she wanted children some day. After being in a few long-term relationships in her life, she had stayed completely single for the past two years. Her original intent was to come in and ask about egg freezing, but after I gave her the statistics on the poor success rates with frozen eggs, she realized that her best choices were as follows: She could continue to hope to meet Mr. Right and become a mommy the traditional way. She could look into adoption. Or she could try and conceive by insemination with donor sperm. After further discussion, we agreed on a plan. She would NOT undergo any fertility treatment at this time. Instead, she would get focused and very actively spend the next year exploring different ways of meeting people. She would also take a voluntary cut in her work load so as to have more free time for dating.

A year and a half later, she called to make another appointment. When I saw her again, she was 36. During this second meeting, she started by reporting her past 19 months, describing her experiences with online dating, joining groups through her synagogue, trying outdoors clubs for active singles, and agreeing to any attempts from her friends and coworkers to set her up. While she had met and dated some men, she joked that she had come to the conclusion that "There just aren't any good single men in Los Angeles".

She reiterated that she was very stable financially, had good support from her mom and friends, and had been thinking this over for the past year and a half, reassuring me (and herself) this was not a rash decision. After discussing her options, she opted to go with donor insemination. She conceived on her second cycle and went on to have a baby girl.

Over the years, she would call our office and give us updates. Her stories of her child's first words, the Chuck E Cheese birthday parties and the joys and frustration of motherhood sounded the same as any of our other patients who graduated from our program. The big surprise came years later when she called to share that she was now happily married and spontaneously pregnant with her second child.

Many studies of children who grew up in fatherless families report higher delinquency rates, lower high-school graduation rates and and more psychological disorders. However, those looked at children who were raised by a single mother after a divorce or accidental pregnancy. In contrast, a research study out of the UK reports very different findings when women become single mothers by choice, through donor insemination. Specific measures discovered in these mothers include greater maternal pleasure in their child, lower levels of anger and perceptions of their children as being less "clingy" in comparison to a control group of married women who also conceived by donor insemination. Possible explanations for this difference include the fact that single mothers by choice represent a special group of women who are motivated, educated, financially successful and surrounded by good social supports.

Careful follow-up with my own patients support these findings. One question I often ask is "If you could go back in time and counsel yourself back when you were considering this big decision, what advice would you give yourself? Invariably, the answer is "I'd tell myself to do it! Going forward with having my child is the greatest thing that's happened to my life." I've even had quite a few patients come back to conceive their second child already.

KEY POINTS TO CONSIDER:- Single mothers by choice often go through many years of deliberation before making the big decision to adopt or conceive. They are different in some ways from women who involuntarily find themselves as single mothers in that their situation is more planned with more careful financial preparation, and without the trauma of having gone through a painful unexpected divorce.- Almost all have a well-established circle of loving support from parents, siblings and friends.- Some of them derive all their satisfaction from motherhood and show zero interest in dating. Others report a improvement in their approach to new relationships as compared to how they were before becoming a happy parent.- Most single mothers by choice have explored traditional relationships initially before deciding on this alternative option.- Single parenthood is not a matter to be taken lightly. There are many resources out there to research before deciding on making this big life decision.

October 20, 2007

Diego and Susy Golberg are a couple in Argentina who began a yearly ritual in 1976. Every June 17th, they took portraits of themselves and their eventual family of three sons, producing a vivid photographic reminder of the reality of aging.

Age plays a very important role in reproduction, especially biological age. Chronological age is determined by what it says on your driver's license. Biological age is different, and arguably more significant. Do you know any athletic women in their late-30's who have the "body of a 20-year-old"? Have you ever seen a 35-year-old alcoholic smoker who looks like he's 50? When it comes to a woman's reproductive capability, it's important to consider her ovarian age in addition to just her chronological age.

Near one extreme, you can have a 43-year-old woman with enough quality eggs remaining that she conceives twins on her own. Or you can have a 19-year-old girl who goes into premature menopause. But for most women, their ovarian age stays fairly faithful to their chronological age with a gradual decline in fertility throughout their life until they reach their 30's at which point the decline accelerates. Then by age 40, the decline becomes very sharp.

It's not possible to tell someone's ovarian age with a single test. You can't tell based solely on how healthy and young she looks. There are a variety of clues about a woman's biological age provided by various methods, some of which are more important than others.

CHRONOLOGICAL AGE: Not surprisingly, the biggest predictor of ovarian function is someone's true chronological age. There is no getting around the fact that if you are 46, you still have poor reproductive outlook, even if you are in the biologically youngest 1% of all the 46-year-olds in the world.

FSH LEVELS: There is a blood test that is typically done on day 3 of your cycle. A high FSH (over 10 IU/l) is suggestive of advanced reproductive aging. A value over 15 IU/L is significantly worse. Consistent values over 25 IU/L indicate that you are likely menopausal. A bad test result is bad news. Unfortunately a GOOD FSH result (under ~9 IU/L) is not necessarily good news. If you are 46 and have a FSH of 5 IU/L, that still does not mean you have the fertility of a 26-year-old. Another warning about interpreting FSH levels involves the possibility that FSH results can look much better than they actually are if your estradiol levels are high on the day of the FSH test. This is why reproductive endocrinologists always know to test an estradiol level at the same time as the FSH level. For example, a day 3 FSH level of 6 IU/L with an estradiol of 53 pg/ml is more favorable than a FSH level of 5 IU/L and an estradiol level of 119 pg/ml. The final point to make about FSH levels is that they are a MARKER of ovarian aging and they are not the CAUSE of ovarian aging. Many patients when told they have a high FSH level often ask what they can do to make the FSH level lower. Making it look lower doesn't change the message that the ovaries are old. This is similar to having a red "engine warning" light come on in your car and inquiring what you can do to cut the wire so the light goes out. It still doesn't change the fact that there is a problem with the engine.OVARIAN VOLUME: In general, younger women have large plump ovaries, because there are more stored eggs left in them. Menopausal women have tiny ovaries that are sometimes so small as to not be visible on ultrasound.ANTRAL FOLLICLE COUNT: Every cycle, before a woman begins developing her eggs, the number of tiny pre-ovulatory follicles is higher in women with young responsive ovaries as compared to in women with older resistant ovaries.RESPONSE TO CLOMIPHENE CHALLENGE TESTING: An old way of testing ovarian reserve or ovarian age involves giving Clomid pills and testing FSH levels before and after. Elevated FSH levels pre or post Clomid are signs of ovarian aging.

INHIBIN B: In contrast to FSH testing, higher levels of inhibin B are good and lower levels are bad.ANTI-MULLERIAN HORMONE: The usage of this hormone to predict ovarian response is a fairly new concept. Again, as with inhibin, higher levels are good. Lower levels are bad.

ACTUAL PERFORMANCE: All of the previous mentioned tests and methods are just predictors of how the ovary MIGHT function. None of them beat actual performance in terms of importance. Even if your age, FSH level and all other testing predict bad news, if you undergo infertility treatment, make a surprisingly large number of good eggs and get pregnant, then you won't really care what the testing predicted. One patient who comes to mind is a woman with small ovaries and a documented day #3 FSH level of 22 IU/L, who came to me for fertility treatment. After I informed her that her chances of success would be low, she polite acknowledged my warnings and then wound up defying the odds, getting pregnant and delivering a perfectly healthy girl at age 41 with her own eggs!

Before asking your doctor to order this whole slew of tests, bear in mind the principle that tests are only of value if they can help us make better decision choices. Knowing that you might have a better or worse outcome may not necessarily change what you decide to do. For example, if you are applying to law school and your LSAT scores tell you that you have a 80% chance of being accepted, but your GPA suggests you have a 55% chance of being accepted, and you are going to go through with the application process anyway despite of which is more accurate, then knowing this additional information doesn't really change your actions. Think about it. I will share more on this very important concept of decision-centered thinking in future posts.

October 16, 2007

I'm presently in our nation's capital for the 2007 ASRM meeting, an annual event when fertility doctors and personnel from all over the world meet to share information. I had posted a notice in my office a few weeks prior to this trip preparing my patients that we would arrange for them to go to my covering colleague's office while I was gone. A lot of them of gave me a supportive farewell saying something like "OK, doctor, go learn something that will help me get pregnant faster!"

Every year, our ability to help our patients improves. I think it's fair to say that if all the infertile couples from thirty years ago who ended up completely childless had full access to the medical treatments available today, over 90% would have gotten to enjoy the blessings of parenthood. Today, the focus has shifted from simply being able to help couples have a child to being able to do it in a safer, less inconvenient, less costly manner and with better obstetric outcomes and fewer complications. We might have also in some ways become TOO good, meaning some questions arise as to which cases are there in which we should NOT necessarily create pregnancies, even if we can.

These meetings are one of the ways in which our body of knowledge is advanced. During this meeting there were about 300 oral presentations and another 800+ presentations in the form of large posters detailing information that physicians, embryologists and other specialists want to share with the world. We listen critically to the presented talks, read the posters, discuss and debate the information and then we individually decide which information we choose to believe and incorporate into our own practices. One shouldn't automatically believe everything. In fact, we can't believe everything, because the information is often conflicting. For example, after many talks espousing the benefits of acupuncture in IVF patients, a controversial presentation this year out of the University of Washington reported that under certain conditions, acupuncture actually was associated with LOWER clinical pregnancy rates.

This is a good example of how new ideas presented from past years inspire the audience to go back home and follow up with their own investigations to present in future years. Over time, a relative consensus develops to persuade us to adopt the things that do work and do away with the things that don't work. This applies to decisions regarding many choices such as different treatments, different medications and different embryology protocols. Even so, you can easily find a dozen different doctors who do things a dozen different ways, all of which work.

For me personally, I will take home some new ideas to try and incorporate into my own practice. My eyes were opened to some new complex ethical considerations that are coming into play. I've met some really nice people with whom to correspond in the future. These include not only physicians, but also experts in nutrition, infertility counseling and alternative medicine. I also picked up the usual brochures and free pens from companies who offer services to help me care for my patients. All in all, it's looking to be a very successful trip! I hope to share some interesting stuff with all of you in future posts.

October 13, 2007

Kim (not her real name) got married early and easily had her first child at age 23. After happily breast-feeding her baby girl for a year, she and her husband used condoms for a year to delay conceiving a second child. Then they stopped all contraception and went about their lives experiencing the joys of being parents to their daughter, not really wanting to have another right away, but not fighting it either. Despite having sex about twice a week, no pregnancy occurred. By age 27, three years later, with still no second pregnancy yet, Kim started being proactive.

By her account "Well, I knew that I could get pregnant, because it happened so easily the first time. My friends got me into tracking my temperature and I soon found some websites to help me. I made a lot of friends online who were going through the same thing. Only they didn't even have their first child, so I felt guilty if I started to stress too much. Over time, however, it started to get very stressful. My period was regular. My temperatures were going up. My mucus was excellent and I certainly could tell every month that I was ovulating. My husband started getting a little weird about my obsession once I started doing the ovulation kits and demanded that we do the baby dance whenever the test told us. I would try and stay in bed not moving for an hour afterwards. I kept thinking, it wasn't this difficult before. Each month, the kits said I was ovulating and then came the long wait and then the devastation when my flow started."

Kim showed me pages and pages of careful temperature charts. She had the classic biphasic pattern, with positive LH testing at the expected times. She and her husband diligently got together during the right times. There was nothing wrong, other than for the fact that she was now 30. Had gone from age 24-27 without contraception, just casually having sex every few days. She then went from age 27 to age 30, faithfully enduring months and months of charting, testing, hoping, waiting and crying.

She continued "I refused to consider anything other than getting pregnant naturally seeing that's how I got pregnant the first time. I kept telling myself to wait patiently, even though every month from the time of ovulation, I would become a nervous wreck. I had nausea, breast sensitivity, headaches and I thought I was pregnant almost every month. I would get cramping and spotting some times, which someone told me was implantation bleeding. But then either my period would come or if I was even one day late, I'd do a test and get a big disappointment. One day at a childrens' party, I was talking to the mom of one of my daughter's friends who was pregnant again with twins. She told me she had seen you, so I finally took it as a sign to come in and get your advice"

Kim and I spent over an hour in talking in my office going over her situation in detail. I performed an ultrasound, which showed a normal uterus and normal ovaries. Afterwards, here was the plan. First we got her husband to come in for a semen analysis. The count was 195 M/cc with 60% motility. This was well above average. We then had several options at this point. We could do empiric treatment with fertility drugs and IUI (intrauterine insemination) or we could do an HSG to check the tubes and uterine cavity. Even though Kim did not have painful periods and was unlikely to have developed tubal blockage after she had demonstrated with her first pregnancy that at least one tube was open way back then. I explained to her that it was even possible that she already had blockage in one tube back then, but could have conceived from the other side. Unlikely, but possible.

Well, this was not the case. The HSG results showed that both her tubes were clean and easily let the dye flow through. However, there was a very interesting finding inside her uterus. There was a small lesion about the size of a small grape. This was so subtle that I could not see it on her plain ultrasound during her first visit. I explained to her that this most likely represented a fibroid or a polyp. A fibroid is more rubbery and a polyp is fleshy, but they both acted the same way to prevent pregnancy, sort of how a copper wire IUD does. Kim had no infertility coverage from her husband's insurance and had paid out of pocket to see me for the consultation and for the tests. I told her that in actuality, a uterine lesion was no longer a pure infertility problem. Although the chance of it being cancerous was very very small, it was reasonable to have it removed. I called her regular OB/Gyn and we arranged for her to get it removed by her, so it would be covered under Kim's insurance plan. It was a simple 20-minute outpatient surgery called an operative hysteroscopy. A small fiber-optic instrument was inserted into the cervix and the polyp was safely removed with a tiny electrified cutting wire. There was no surgical incision nor scarring. It wound up totally covered by her insurance as a legitimate gynecological procedure. The microscopic report on the polyp came back as totally non-cancerous.

After the surgery, Kim came in with her husband to discuss their options. Their daughter was now 7 and they felt that it was already too big an age gap for the next child and totally unlike how they felt before, they now wished to proceed with aggressive fertility treatment to hurry and conceive. I explained to them that we had found a real problem and that we had eliminated it. Therefore, they should give consideration to being conservative in their choice of options. We made a deal that they should try on their own for six months and if they were still not pregnant by then, we could do fertility treatment.

Two months later, Kim called us in tears to say that she had missed her period and that her urine pregnancy test was positive!! She went on to have another girl. And two years later, she had a boy. Both were conceived 100% naturally after removing the offending lesion.

KEY POINTS TO CONSIDER:- Uterine lesions can cause abnormal bleeding and cramping. Even small ones can cause infertility, by interfering with implantation.- If a real problem is found and eliminated, it's often worth it to try on your own for six months to a year.- If you have been trying to conceive for more than one year, give strong consideration to getting a semen analysis and an HSG.

October 09, 2007

Endometriosis is an a condition where the tissue that normally is found inside the uterine ends up growing and proliferating outside the uterus. It affects an estimated 1 out of 10 women in the world. However, that estimate is subject to dispute because the only sure way to tell if someone has endometriosis is to look surgically.

Every month, in a normally cycling woman, the lining of the uterus builds up in preparation of nourishing any fertilized egg (embryo) that comes into the uterus. If no viable embryo shows up, then the lining is shed in a process known as menstruation. Most of the blood and tissue will flow out the cervix and out of the body. However, in every woman who has open tubes, some of the blood and tissue will flow backwards through the tubes and into the abdominal cavity.

Under normal circumstances, the body's immune system will clean up this material. However, in an abnormal circumstance, the internal buildup of menstrual debris overwhelms the body's clean-up capacity and results in the tissue building up, taking hold and digging in. These endometriosis implants can cause intense pain (but not always) and they can contribute to infertility. Some of the ways that endometriosis can cause infertility is by scarring the tubes and scarring the areas outside the tubes. The process also creates a hostile inflammatory environment so that eggs die faster, even if they somehow traverse the obstacle course created by the scarring and make it into the tubes.

Solutions to address the pain include surgery and medications. Solutions to address the infertility include IVF (to completely bypass the endometriosis) or a combination of fertility drugs and insemination. The principle behind using fertility drugs and insemination is related to flooding the system with excess eggs and sperm. Even though the eggs are still subject to a hostile tangled environment there is an advantage to having multiple eggs. There develops a higher chance that even though most eggs will be trapped and die, perhaps a single lucky one can elude the endometriosis and make it to safety to be fertilized and form a baby.

October 05, 2007

There are extreme highs and lows in the typical work week of a Reproductive Endocrinologist. Throughout my career, in one manner or another, I’ve had the chance to share in the joys of families as they have welcomed over eight hundred happy healthy babies into their lives. I’m ever thankful for these experiences. However, along with those “good” pregnancies, there have been hundreds of other times when I’ve endured alongside my patients their utter sorrow as they suffer a pregnancy loss. Many of you may yourselves have had one or more miscarriages before. And only you can understand the many thoughts that run through your minds during these tragic events.

So many questions come to your mind. Was it something I ate? Was it that argument I had at work with that difficult client? Should I not have lifted that bag of groceries? It’s normal human nature to search for a reason or cause for events. However, in the case of an isolated first miscarriage, there is usually no reason other than for the cruel truth that miscarriages “just happen”. Even the healthiest women will suffer miscarriages. The rate in the general population is about 1 out of 6 pregnancies ending in a loss. For women over 35, that risk is even higher. This is usually due to the fact that sperm and eggs are not always perfect. If the specific sperm or egg that happened to create this pregnancy was in any way imperfect, it could be just good enough to conceive, but not good enough to thrive and survive. Nothing in the world could have prevented it. Yes, there are other miscarriages that arise from maternal factors. In these cases, a genetically perfect conception fails to survive because of a bad environment inside the uterus. This might be due to a physical defect, such as a fibroid or polyp or it might be due to a hormonal abnormality.

After sufficient grieving, the most important thing to do is to make the right decision. For most people, the right decision is to just go back to trying on your own again. For others, the right decision is to go seek help.

Many factors influence what is the right decision:

AGE: If you are younger, then it is not as crucial that you get a thorough workup and are you usually told to wait and get checked only if it happens again. OB/Gyn textbooks classically use three miscarriages as the threshold at which you should launch an investigation. However, if you are over 35, you might want to seriously look into it even if you’ve had two miscarriages. The reasoning is because if there is something treatable, then you need to take action before you run out of precious time in your lifetime of fertility.

NUMBER OF MISCARRIAGES: If this is your first miscarriage, most doctors would not recommend a workup. If this is your third or greater miscarriage, then most doctors would agree that a full workup is in order.

NUMBER OF HEALTHY PREGNANCIES: Someone who has six healthy children with three miscarriages interspersed between those healthy pregnancies is not in as great a need of a thorough workup as someone who only has three miscarriages and no other pregnancies.

SUSPICION OF A SPECIFIC PROBLEM: Women who have other clues for health problems, such as abnormal bleeding, known uterine problems, chronic medical issues or a significant family history of genetic or medical problems should consider getting help sooner rather than later.

FERTILITY: A woman who gets pregnant once every two years and has three miscarriages over six years has greater urgency to seek help than one who had three miscarriages in one year and seems to get pregnant quite easily.

KEY POINTS TO CONSIDER:- Isolated miscarriages, while very sad, are part of normal human reproduction. The focus should be on getting as healthy as reasonably possible (diet, exercise, weight control, avoidance of smoking and other bad habits, stress management) and getting emotionally ready to conceive again.- After a miscarriage, avoid searching for ways to blame yourself or looking for some real or imagined reason that caused it. - If time is not urgent for you, then wait two to three months to emotionally recover. Spend that time catching up with the things in life that got put on hold during the weeks of dealing with the miscarriage. Take a break and enjoy activities that you may have put off for a time. However, if time IS urgent for you (if you are older, for example), then it’s probably better to just keep trying right away rather than wait three months. Don’t necessarily seek medical assistance, but don’t use contraceptive measures to avoid getting pregnant.- Contrary to popular belief, for the majority of women who have had miscarriages, odds greatly favor that the NEXT pregnancy will be a healthy one rather than another miscarriage.- Recurrent miscarriages should be seriously addressed as there might be a treatable cause.

Watch for future posts that discuss some of the causes of habitual miscarriage.

October 01, 2007

Kristen is an ambitious 33-year-old half-Asian half-European graduate student. After seven happy years of marriage with regular sex twice weekly and no birth control, she and her husband have only one pregnancy together, an early miscarriage six years ago, which resulted in a D&C. Since then, there have been no more pregnancies and despite their busy career schedules this year, they really want a baby now. So they decided to take action and seek help from a Reproductive Endocrinologist. She was referred to see me by the recommendation of her sister, who coincidentally, is a RE herself on the East Coast.

Previously, Kristen had been working closely with her OB/Gyn who started some basic testing. Her husband’s sperm was normal (84 million/cc, 90% motility), even though he was still smoking a half pack per day and she reported that some basic hormonal testing done on herself came back all normal, although I don’t have information regarding what exactly was tested. She reported that her periods were regular, but they were a little prolonged in that they came every 35 days or so.
Her frustration stemmed from the fact that nothing was wrong with her and her husband. It was compounded by the fact that she had gotten pregnant in the past without a problem. In addition, she had spent several hundreds of dollars already on fertility monitors and test strips.
I told her that we had several options at this point. We could do an HSG (hysterosalpingogram), which is an X-Ray test to see if her tubes are open or blocked. We could also give her Clomid to see if it helps the quantity and quality of her ovulation. Or she could keep trying to get pregnant on her own. I advised against choosing this last option. She and her husband discussed it and decided not to be too aggressive yet, so they opted for three cycles of Clomid, without ultrasound monitoring. She did self monitoring with temperature and urine tests and had a positive ovulation test each month. After three months of Clomid, she was still not pregnant, and as we agreed beforehand, we now proceeded to do the HSG.

The HSG revealed two things. Her tubes were clear. Her uterus was normal. This is an example of the classic diagnosis of UNEXPLAINED INFERTILITY. The sperm, ovulation, tubes and uterus show no major problems, yet pregnancy is still not happening. This is the point where many patients are told by their doctors “There is nothing wrong. Keep trying. Goodbye.”, leaving the patient completely frustrated.
The proper approach to unexplained infertility is to offer options. Yes, one choice is to keep trying naturally, but for a patient who has already been doing that for seven years, that’s not the best option. Another choice is to help the couple “cheat” to get the odds in their favor. I usually explain it like this.- A normally fertile couple has a 25% chance of getting pregnant each month.- A couple with unexplained infertility has about a 2% chance of getting pregnant each month on their own.- By doing simple intrauterine insemination (IUI) in conjunction with fertility medications, we might be able to bring that up from 2% to 10-20%, depending on how many mature eggs are grown.- By doing IVF, we can in a single month bring the odds from 2% to about a 40-60% chance of pregnancy.

So rather than patiently accepting a 2% chance each month, Kristen and her husband opted to do a cycle of IUI treatment. She started by taking five days of Clomid followed by two days of injectable gonadotropins. When she returned for her ultrasound, she had two mature follicles growing on her left ovary. She took a shot of hCG to trigger ovulation and insemination was performed two days later. A blood test twelve days later showed an hCG value of 60 IU/L, meaning she was pregnant!
She is currently in her second trimester and is due to deliver early next year.

KEY POINTS TO CONSIDER:- Unexplained infertility is a common diagnosis for infertile couples. It basically means that there is nothing wrong (that we could find).- There are many good options for dealing with unexplained infertility, including fertility medications, IUI and IVF.- Had she chosen not to do any treatment, there was still better than a 40% chance that she would be pregnant on her own within the next 5 years.- It is OK to be proactive and take measures to improve your odds of pregnancy, even when there is nothing wrong found on testing.

By the way, my farewell words to her and her husband when they joyfully graduated from our office at 12 weeks of pregnancy with a single healthy-looking baby was this advice. After the baby is born, she should breast-feed as long as she wanted. THEN, they could try on their own again for six months to a year. If they still weren’t pregnant by then, they could always return for another treatment cycle to get their second baby.

September 27, 2007

Dear Dr. Lee,I was wondering if I could run my situation by u and
get some advice or possibilities on what my prob. could be. I have been happily
married for over 10 years now. I got preg about 10 years ago when we were first
married and miscarried. I have not been preg. since. My periods were always
irregular sometimes absent for months sometimes lasting for 3-4 weeks. I had an
ultrasound and was diagnosed with PCOS - I have been on metformin for 5 months
now and did 2 months of clomid and 3 months of letrozole with nothing. Now I am
waiting for my husbands insurance to kick in to have laparoscopic surgery. My
husband has been tested and he is fine so the prob lies somewhere within me -
what could this be and do u think I could ever even become pregnant. I am 26.
Yes, I got married young. I am desperate because my mother and all three of her
sisters ended up having to have hysterectomies before they were in their
thirties. Any advice would be appreciated. Thankyou."B", from Arkansas

Dear "B",Can you provide some additional information?Did you grow any follicles on the Clomid or Letrozole?Did you ever try injectable fertility medications?What is your approximate height and weight?Did you have an HSG already to see if your tubes are open?Dr. Lee

Dear Dr. Lee,Just within the past two years we have decided to look into this and after a
consultation and an ultrasound, I was diagnosed with PCOS. We also had my
husband's sperm tested which came back fine. The doctor put on metformin and
clomid. I did both for two months with no results. I then continued the
metformin and did three months of letrozole. This too ended with no results. We
are now at a holding point waiting for my husbands medical insurance to go into
affect to take the next step in having laparoscopic surgery to find out more.
Being that this was all paid out of pocket and we had no insurance, ( I would
imagine this is the reasoning ), I was never told about any follicles growing
while on clomid or letrozole. I did recently give a blood test to see if I was
even ovulating but have yet to hear the results. I have not tried the
injectable fertility treatment because after discussing it with my doctor,
decided to start with a less expensive approach again until the insurance takes
affect. I am not sure what a HSG is to see if my tubes are open and suppose if
I had had one I would know so I guess I have not had that done. My mother and
all three of her sisters all had to have hysterectomys in before or in their
early thirties so at 26 I am getting more anxious. I am racking my brain trying to figure out what
could possibly be keeping me from becoming pregnant especially since I was able
to get pregnant 10 years ago.I am 5'4" and weigh 190 although before
starting the metformin I weighed 211. As far as symptoms other than
infertility, I have literally every symptom of PCOS in addition to migraine
headaches, inability to sleep and when I do I have to have atleast 12 hours and
even then it is difficult to wake up, and mood swings where I just get so
depressed I cry (even tho I am normally a very happy fun person).
A cat scan ran during one of my migraine trips to the hospital came back normal.
The metformin seems to be working as I have been having normal, regular periods
and little pain. Any information on what I need to do and what this could be
would be greatly appreciated. Thankyou.

P.S. I have been nausiated and vomiting some the past two days and realized
that this occurs without reason maybe twice a month and lasts 3-4 days. I did
some more research on the internet and because of the pcos and being insulin
resistant, do u think I could be diabetic? I noticed this amongst my "mood
swings" and "hunger" and others were symptoms. Sometimes I wake
up in the morning and cant make it to the cupboard fast enough for something
sweet. Anyway, just a thought - I have been trying to put all this together for
years now and I want to thankyou for all your help. I will be watching for your
answer. Thankyou again.

Dear "B", You have been brave to endure such a long time suffering from PCOS, especially in the context of the frustration of not knowing why you were teased with a brief glimpse of being pregnant way back then. I do congratulate on your having been happily married all this time despite the obvious great stress of infertility. As, always, please accept this feedback in the context of my not knowing more about you and not having the opportunity to examine you. I would suggest you take the following information as potential topics of discussion. Many reasons would lead any RE to agree with you having the diagnosis of PCOS (Polycystic Ovarian Syndrome). This is a disease that is not entirely understood, even today. However, we do know that it is somehow related to faulty insulin metabolism. You likely inherited a bad gene that makes your body unable to respond to insulin normally (I wonder if there is diabetes in your family). Because of this deficiency, you end up having high levels of insulin, which can interfere with egg development. It can also cause a host of other problems, including weight gain, menstrual abnormalities, hairiness, acne and increased miscarriage risk. Your doctor wisely gave you metformin (Glucophage) to address the insulin issue. It is not surprising that you have lost 20+ pounds since starting it. Keep up the good work of taking your metformin, watching your carbohydrate intake and gradually increasing your exercise level. I have seen patients start ovulating on their own after losing weight on metformin. I truly hope it happens for you. In the event that you do not ovulate soon, then it's time to consider ovulation medications such as Clomid, Letrozole or best of all, injectable gonadotropins. Unfortunately, when you failed to get pregnant on these medications in the past, we do not know if you grew follicles and ovulated well, but just didn't get pregnant OR if you failed to ovulate even with the medications. If it's the first case, meaning you ovulated consistently and still didn't get pregnant, then I would suggest an evaluation of your tubes. This is best done with a non-surgical x-ray procedure called an HSG. The surgery that your doctor proposes is a reasonable option, but not the best one, in my opinion. Now, if it's the second case, that back when you were on the Clomid and Letrozole, you didn't even ovulate, then the obvious best plan at this point is to work harder at getting you to ovulate. So how do we do that? In your situation, it would be reasonable to try injectable gonadotropins with close monitoring to see that you actually are ovulating! If there are no problems with your tubes, you should get pregnant with a high percentage chance once you are ovulating. As for your nausea, obviously you know to do a pregnancy test first. The relationship between diabetes and PCOS goes something like this. A normal person is one whose body uses a little bit of insulin to successfully bring the blood sugar levels down easily. An insulin-resistant PCOS person is one whose body frantically uses a lot of insulin to successfully bring the blood sugar down. A Type II diabetic is someone who despite frantically producing a lot of insulin still can not bring the blood sugar levels down. So while it is possible that you are at risk of becoming diabetic or that you are already diabetic, most likely you are not yet. A combination of diet, exercise and metformin can hopefully delay your development of diabetes until you are 100 years old! Your vivid description of your sugar-craving is classic for PCOS patients. However, you are already on the metformin, so I would have expected improvement in that area. Perhaps a combination of a higher dose (ask your doctor), more will power and REGULAR fun exercise can get those craving under better control so that you can keep losing even more weight.

KEY POINTS TO CONSIDER:- Ask your doctors if they can focus on helping you ovulate in a proven documented fashion first before resorting to the laparoscopic surgery. If you ovulate, but still don't get pregnant, then go ahead and evaluate your tubes and uterus, either with an HSG (preferred) or with the surgery.- Continue your great progress regarding weight loss and getting healthier.- Based on the limited information you have given me, I would be very optimistic about your chances of having a baby within the next few months, provided you make the right decisions regarding treatment.- Once you get pregnant, keep on the metformin as many believe it can help combat the higher risk of miscarriage that PCOS patients have when they don't take metformin.GOOD LUCK!

September 23, 2007

Last week was an especially busy one for me with ten new infertility patients seen. I love how all their stories are uniquely different. One patient in particular had been infertile for almost three years and brought a neat stack of color-coded temperature charts to show me! This follows a trend I've been noticing lately with more and more patients turning to the internet for fertility information, often going to special websites that provide tools for charting ones cycles, either for free or for a small fee. Overall, there is more benefit than harm to doing this if used correctly, but in this patient's case, it was harmful in that she wound up doing it TOO long before getting professional help, thereby wasting several of her potentially fertile years.

The first thing that needs clarification is this. How exactly does ones body temperature have anything to do with fertility? It all has to do with a hormone we discussed previously known as PROGESTERONE. When a egg is ready to be released, the cells surrounding the egg produce progesterone. Over 95% of the time, this is accompanied by actual physical release of the egg. There are some unusual instances when there is a rise in progesterone, but no actual ovulation, but this is rare.

Elevated progesterone levels lead to elevated temperature. However, other factors also affect body temperature. Some of these include activity level and environmental temperature. This is why, in an attempt to standardize conditions, basal body temperatures are intentionally measured first thing in the morning after complete rest (sleep). Normal body temperature is 98.6 degrees Fahrenheit (37 degrees Celsius). Basal body temperature, on the other hand, is a little cooler, about 98F or 36.6C. This makes sense because when at rest, you don't burn as many calories. The levels of progesterone that are present after ovulation will make ones BBT rise about half a degree F. So a normal BBT chart should consist of a range of lower temperatures before ovulation and a range of higher temperatures after ovulation.

Now, here are what I consider to be the PROS and CONS of charting ones BASAL BODY TEMPERATURE.

GOOD: It can bring some peace of mind, giving you "something active to do" while you are trying on your own. Remember that for most couples who want to have a baby, unless they already have some suspicion of an existing infertility factor, their best strategy is try on their own just having sex every 1-3 days. This should continue for six months to a year to give things an adequate chance. However, some of us have good proactive tendencies and like the feeling of taking action. Charting ones temperature is a good safe way of channeling these energies.

GOOD: It can alert you early if you are not ovulating, so that you will know to get help sooner. If your temperatures don't rise in the second half of the cycle, this is a tip-off that you are likely not ovulating. This early warning can help you know to get help right away rather than wait a year. One possible reason for not ovulating is if you suffer from PCOS.

GOOD: It can play a part in a nurturing supportive environment, which lowers stress and therefore helps conception. Many of these websites allow women to copy or even email their charts and share them with friends. Again, this fosters an atmosphere of supportive community which has many positive effects.

BAD: Temperature charting can NOT be used to signal the best time to have intercourse. By the time you see the temperature rises, it is already too late. Therefore charting temperatures more tells you when your fertile period has already passed and gone rather than telling you when it is about to come.

BAD: Temperature charting does NOT help increase the chances of conceiving for couples who already have sex regularly. As I mentioned in an earlier post, the best way to get pregnant naturally is to have sex every 1-3 days. It's only when sex is very scarce that you can benefit from meticulous timing.

BAD: For some people, obsession with temperature charting leads to INCREASED stress which in itself, could lower their chances of conceiving. I've encountered many patients for whom this was the case. They actually reported starting to feel worse (much more tense) from the time they first began charting.

BAD: For some people, obsession with temperature charting leads to DECREASED frequency of sex, thereby lowering their chances of conceiving. I've seen patients who were inaccurately predicting their peak fertility time. It was actually later than they thought. But since they thought it had already passed, they stopped having sex that month, ironically missing the most favorable times.

Overall, charting ones BBT can be done in the context of a grander strategy that takes care to have a backup plan for seeking professional help when too much time has passed with no pregnancy still.

September 20, 2007

Not all fertility treatment involves injectable medications. However, when it comes time to discuss this topic with the patients who do need to take it, there is a mix of reactions ranging from calm acceptance to sheer panic. Whenever I hear the response that "I don't do well with needles", I'm reminded that I have yet to hear anybody say "Oh, that's wonderful. I do great with needles" It's normal to want to avoid needles and the pain that we associate with it. However, in reality, those nightmares of huge needles are just myths. In reality, I'd say close to 99% of patients who end up taking injectable medications to help in them develop good eggs end up saying it wasn't anywhere nearly as bad as they imagined. The needles are actually short and thin and in many cases come in the form of space-age injection pens. They are NOTHING like the needles in the picture.

Here are links to the instruction videos for the most common brands of ovulation induction medications:

September 16, 2007

A Reproductive Endocrinologist (RE) is a doctor (M.D. or D.O.) who has completed specialized training in the field of medicine dealing with the hormones that govern conception. Sometimes, rather than calling them RE's, people refer to them as infertility specialists.

However, the term infertility specialist is a generic, unofficial term and can really apply to anybody who has a particular interest in fertility. Any family medicine doctor, general OB/Gyn doctor, acupuncturist, herbalist, nutritionist or other type of medical personnel can label themselves as a specialist in infertility.

In contrast, to consider oneself a reproductive endocrinologist, one must go through a very specific educational track. They must first graduate from college and attend four years of medical school. They then must get accepted into a residency in OB/Gyn where they will spend four years learning how to deliver babies, operate on the uterus and ovaries and take care of all aspects of women's health. During this time they will pass written examinations and then officially get their license to practice medicine. After these four years, they must apply to the limited number of accredited RE programs in the US. Once accepted, they will spend an additional three years focusing on learning infertility diagnosis and treatment.

The typical work week consists of meeting with patients to discuss their fertility issues, performing office procedures such as ultrasounds and inseminations, performing surgery such as laparoscopy and hysteroscopy and performing ART procedures such as egg retrievals and embryo transfers, all for the purpose of helping couples have babies.

While there is no clear shortage of RE's, the demand for their services is great and continues to increase as society displays a trend to delay childbearing until older age when it becomes more difficult. It is estimated that there are 1 million practicing physicians in the US. Out of those, there are about 1400 RE's or 1 out of every 700 doctors, making for a very limited subspecialty.

September 12, 2007

A few weeks ago, I was giving another infertility lecture to the third-year medical students at UC-Irvine College of Medicine. There was a visiting exchange student from one of the Scandinavian countries and our discussion turned to how IVF was free for all the citizens there, paid for by the government. He mentioned that the trend was continuing further in that there was talk of extending the free IVF services to all couples, regardless of sexual orientation. Denmark has been successful in keeping up the birth rate, while many other European countries have seen a decline in the number of babies born each year as a percentage of the number of women. A story in the news yesterday even tells of a Russian governor declaring a special holiday for people to stay home and have sex in an attempt to boost their low birth rate.

In the US, however, IVF is not universally free but rather, is limited to couples with the greatest demand for it. The reason we can't offer IVF to everyone is that we are limited by a lack of manpower in how many cycles we can perform. A single IVF cycle can require several dozens of people including reproductive endocrinologists, embryologists, nurses, medical assistants, anesthesiologists and laboratory personnel. In my opinion, if we try to push our limits and do more cycles that we can comfortably handle, we run the risk of decreased success, especially with respect to the work of the embryologists. They have to meticulously handle the delicate eggs, sperm and embryos. The process has to be tedious and careful in order to be successful and it is especially important that they are not overworked.

These are the categories of patients who are the prime candidates for IVF.

1. WOMEN WITH BLOCKED OR MISSING TUBES: This was the original reason IVF was developed. In nature, to achieve a pregnancy requires the Fallopian tubes picking up the egg and transporting the sperm to go meet the egg. With IVF, this process is entirely bypassed and the sperm and egg are perfectly united outside the body.

2. MEN WITH EXTREMELY BAD SPERM: In the past, men with very bad sperm had only two options if they wanted a child -- adoption or donor sperm, or vasectomy reversal in the case of those men who have had vasectomies. Nowadays, we have the ability to easily inject a single sperm into a single egg with a process called Intracytoplasmic Sperm Injection (ICSI) and ensure fertilization.

3. COUPLES WHO HAVE TRIED EVERYTHING ELSE ALREADY: IVF is a highly effective treatment for patients with unexplained infertility. Couples who don't get pregnant on their own and those who don't get pregnant with inseminations will often succeed with IVF.

4. COUPLES WHO NEED SOME CONTROL OVER THE GENETICS OF THEIR BABIES: With Preimplantation Genetic Diagnosis (PGD), it now is possible to get information about an embryo prior to implanting it. We can tell gender and whether or not certain genetic defects may be present, thereby allowing us to choose which embryos will have a chance to give birth.

5. SITUATIONS IN WHICH ONE WOMAN'S EGG ARE USED TO DEVELOP A BABY IN ANOTHER WOMAN'S BODY: In the past in order to have a baby, you needed to have good eggs and the ability to carry a pregnancy. Nowadays, if you lack eggs, you can have a baby with the help of someone else's eggs. If you have good eggs, you can have someone carry your baby for you.

There is one last category of couples who are NOT the most medically appropriate for IVF, but yet choose to do so because of personal preference. These are COUPLES WHO WANT A BABY ON DEMAND. Many couples PROBABLY have a good chance of being able to conceive either on their own or with low-tech treatment within the next 2-3 years. However, they don't want to take the risk of waiting that long only to find themselves still not pregnant. So they make the choice to do IVF to get pregnant right away and not have to worry any more.

Thirty years ago, none of the above couples had the privilege of doing IVF to get a baby and would most often end up childless (unless they adopt). With the advances today, miracles happen all the time for couples seeking to grow a family, and my team and I are reminded daily of how blessed we are that the harder we work, the more likely that one more happy baby will come into the world. I realize this sounds overly sentimental, but we really do enjoy our work. =)

September 08, 2007

I polled some non-medical friends and acquaintances on what
came to their minds when they heard the word HORMONE. The responses varied
greatly from raging emotions to vivid sexual imagery. Suffice it to say that
this word is one for which the difference from its everyday general usage to
its intended scientific meaning is huge. In medical terminology, a HORMONE is
very simply a chemical substance which acts a biological messenger.

The reason we associate it with emotions and drives is because one of the
targets that hormones act on is the brain, which of course, governs our
feelings and actions. When it comes to fertility, hormones play a key role. The
brain has to talk to the ovaries to tell them prepare an egg for ovulation. The
ovaries have to tell the brain that they are responding. They also have to tell
the uterus when to get ready for possible implantation of an embryo. If a
pregnancy is successfully established, the new set of hormones produced by the
developing fetus tell the body that a pregnancy has occurred. This can lead to nausea,
moodiness, cravings, breast changes and the many other symptoms associated with
pregnancy.

Here are some of the key hormones involved in reproduction along with the
basics regarding each one.

FOLLICLE STIMULATING HORMONE (FSH): This hormone comes from the brain (more
specifically the pituitary gland, which hangs from the base of the brain). It
travels through the bloodstream and tells the ovaries to get an egg ready. Once
the egg begins to respond, another hormone (estrogen) is sent back to message
the pituitary to ease up on the FSH production. This is called feedback. Women
whose eggs are all too old or too few in number will fail to respond to the
FSH. When this happens, the pituitary does not ease up, but rather starts
cranking out ever higher levels of FSH. This is why high levels of FSH are a
sign of ovarian failure or near-failure.

A very different type of problem happens in women who are
anorexic, very stressed, or extremely thin. They may not produce FSH properly
and therefore, may not develop their eggs properly. This could result in them
not having periods.

Women with PCOS produce FSH normally. But their ovaries are surrounded by high
levels of male hormones and therefore need even higher levels of FSH in order
to properly develop the eggs. One way to get this accomplished is to boost your
own natural FSH production using drugs like Clomid. Another way is just to
supply large amounts of FSH from outside sources, rather than counting on you
to produce it yourself.

ESTROGEN: This hormone is produced by the developing eggs. It is what makes the
cervical mucus more watery. It is what makes the uterine lining thick and
healthy and ready to support implantation. Estrogen goes back to the pituitary and
shuts off the FSH.

LUTEINIZING HORMONE (LH): This comes from the same place as FSH. While FSH
tells the eggs to develop, LH signals the eggs to release. Once the LH signal
is sent to the ovary, the egg releases in about 36-40 hours later. This is the
magic hormone that is measured in the ovulation prediction kits.

PROGESTERONE: After ovulation, this is
made in large quantities by the remaining “shell” of the follicle. It is
responsible for the rise in basal body temperature seen after ovulation. If the
progesterone levels drop, the lining will come out as a period.
HUMAN CHORIONIC GONADOTROPIN: This hormone is made by the fetal tissue and is
what makes a pregnancy test turn positive. This hCG also happens to be
available as a drug to trigger ovulation because it mimics the action of LH.

Watch for more details about each of these hormones in future posts. As you can
see, there is actually nothing sexy or emotional about hormones themselves.
However, by regulating our reproductive systems, they actually do play a
crucial role in the wonderful feeling we get from watching the babies that result.

September 04, 2007

Linda is a very confident woman in her early 30's who has a
very successful career in sales in a science-related field. She and her husband have been married for six
years but didn’t want kids right away. So, she had been diligent about taking
birth control pills up until a year ago, when they first made the decision to
start trying. She was originally started on the pill back in college to help
regulate her erratic cycles. After going off the pill, her period had returned
although sometimes coming in 26 days and other times as long as 34 days.

When she first came to see me for consultation, she brought
in a stack of color-coded temperature charts that she had created with the help
of some ovulation-tracking websites and dropped them on my desk in frustration.
She told me her story with sadness. She and her husband had put off having
children until now because they both loved their jobs. They also both had a
great love of traveling, each year typically going on two major vacations and
countless minor ones. They had moved into their dream home two years ago and
realized it would be an ideal time to start their family. Everything had been
perfect up to that point. Now she is convinced that she waited too long and
greatly regretted her decision. I told her that it’s very common to feel this
way, but in reality, she most likely had not done anything wrong to permanently harm to
her fertility. She continued her story.

When they went off the pill, they were expecting their life of perfection to
continue so that they would get pregnant right away. However after eight months
of nothing, Linda began being more proactive with diligently charting her
cycles. The frustrating part was that some months, the temperature curve looked
classic, like in the textbooks, with a clear increase in temperature during the
second half of her cycle. However, there were also months in which it looked
like a jagged set of random numbers. Her urine ovulation prediction kits had
turned clearly positive in some months, with the test line definitely darker
than the control line. However, there had also been months where she had a
light line that stayed light for 5 days (never darker than the control) and
then went negative. And then each month, there was the excruciatingly long wait
to see if she was pregnant or not. She said she and her husband wanted to
forego all vacations this year and put that money towards doing an IVF cycle to
see if they can pregnant instantly.

I reviewed her charts with her and agreed that it was likely that she was
ovulating some months and not ovulating on other months. I also confirmed that
she had been off the birth control for eight months prior to embarking on the
massive charting, and that she had been charting for a year now. Since she was
on day 13 of her cycle on the day she first saw me, we had the opportunity to
check with ultrasound to see how her follicles here doing. We found that her
right ovary had a 14mm follicle. Nothing else was present on either ovary. Her
lining was good at 8mm thickness with a triple layer. I explained to her that
the follicle would have to grow to at least 17mm or better before it could
ovulate. After talking for an hour total about other potential fertility
factors, we came up with the plan of following this cycle using ultrasound and seeing
how it correlated with her ovulating testing.

Two days later, she called the office excitedly saying she tested positive on her ovulation stick! We
brought her in the next day for a repeat ultrasound and saw a single 18mm
follicle on the right. So far, so good. She and her husband got busy for the
next few nights. She then came back two days later for an ovulation check. To
our slight surprise, the follicle was still there and had now grown to 25mm.
She also reported vague abdominal pain on that side and even some mild
spotting. The follicle had a clear appearance and did not have cloudiness
inside as is sometimes seen when a follicle DOES ovulate, but somehow just fills
with blood giving rise to what is called a corpus luteum. So even though her
ovulation kits detected a surge, she had not physically ruptured the follicle.
She had not physically ovulated. After another three days of intercourse, she returned for a final ultrasound. This time, there was a 31mm follicle on the right, still not ovulated. Almost two weeks after the positive surge, her period came. Optimistically, I advised her to hold off on
IVF and start with something much simpler first.

In the next few weeks, we did many things, the most notable being diagnosing
her with insulin resistance and starting her on metformin as well as confirming
her husband to have a normal semen analysis. She had no apparent risk factors for tubal disease, so we held off on getting an HSG yet. With her next cycle, she was
started on clomiphene citrate and monitored using ultrasound. By day #12, she
had a lovely follicle on each side, each measuring 16mm. Three days later, her
ovulation testing turned positive and she came back for another ultrasound,
which showed one follicle to be 22mm and the other to be 20mm. She and her
husband got together a lot in the subsequent days. Three days later, she returned.
This time, ultrasound confirmed that both follicles were no longer there. They were
gone for certain, presumably ovulated! She was scheduled for a blood pregnancy
test in two weeks, but she “cheated” two days early and did a urine test,
calling us immediately with the good news. She went on to have a healthy baby
(just one). She beamed about how she had only spent a few hundred dollars and
was thus able to take the money they saved for IVF and take a vacation to Tokyo
during her second trimester. =)

KEY POINTS TO CONSIDER:
- An ovulation test does not actually detect ovulation. It detects a hormonal
surge that is SUPPOSED to trigger ovulation in the majority of cases. However,
it does not guarantee ovulation, as we learned in this specific example. So it’s
very much OK to start out doing ovulation tests on your own, especially if it
gives you something to do and if it gives you peace of mind that you are having
the proper surges. However, if enough time passes and you are still not getting
pregnant, then it’s time to take advantage of professional guidance.
- Women don’t ALWAYS ovulate or NEVER ovulate. There are many who will ovulate
in some months and not in others.
- Some people may mistakenly equate going to see a reproductive endocrinologist
with leaping into IVF or injectable fertility drugs. More often, there are
simpler options to start with.
- If a particular strategy has not
worked for six months, it's a good idea to consider trying something more
effective, even if it's only a little more effective.

September 02, 2007

In an earlier post, we looked at the world explosion in the number of healthy babies born through IVF, gradually improving in the past 25 years and rapidly so in the past 10 years. But what exactly is the concept behind the success of IVF? How does it help so much?

Recall our past discussion regarding how to make a baby. You need to start with the two components: the sperm and the egg. To have a baby, you need to have a genetically perfect sperm unite with a genetically perfect egg. In nature, the way this happens is the egg emerges from the ovary during the process of ovulation. Then it will float around freely inside the abdominal cavity waiting for a chance to be picked up by the Fallopian tubes.

You know those things that they use to automatically clean swimming pools. They float around on the surface and randomly suck up leaves and debris? The Fallopian tubes work a lot like that. After ovulation, the egg floats in a thin layer of fluid. Imagine if you will, tossing a ping-pong ball into a swimming pool and waiting for the pool cleaner to suck it up. Eventually, given enough time, that sweeper will make its rounds throughout the entire pool and suck up everything. However, eggs have a limited life span of less than 24 hours. So in our pool analogy, imagine if the ping-pong ball was set to self-destruct in 2 hours, that would make it unpredictable whether it would make it into the sweeper before that time was up.

So IVF helps in at least three ways.1. The sperm and egg are physically brought together for sure. This is a big advantage. No longer do you have to rely on the tubes to suck up the eggs. This is especially important in patients with blocked tubes or with extensive endometriosis or pelvic adhesions (scar tissue)2. With, IVF, we start out with multiple eggs instead of just one so there is a much higher likelihood that at least one of the sperm-egg pairings will consist of perfect sperm and a perfect egg coming together.3. The sperm can be directly injected to fertilize the egg. Without help, even if the egg makes it into the Fallopian tube, and there is sperm waiting, that does not guarantee that a sperm will actually fertilize it, either because of failure to physically collide or because of deficiencies in the sperm that make it less capable of entering the egg.

IVF is a great treatment for infertile couples with tubal problems or severe sperm problems. It is also a good backup plan for times when everything else fails.

August 30, 2007

Just the other day, a young woman stuck up a conversation with me at the dog park while our dogs were playing. When she learned what I did for a living, she excitedly told me "It's great I met you! My husband and I want to start trying for our first baby next year, so I've been meaning to get ready by learning how to take my temperatures. Do you have any suggestions?" As it turned out, she had many girlfriends who were trying to conceive and were always talking about taking their temperatures, charting their cervical mucus , scheduling their times of intercourse and all that. She sounded almost surprised when I shared with her that for most couples, meticulously trying to time their intercourse is a waste of time (with a few exceptions which I'll cover later on in this post).

Let's start with some basic concepts. Every couple has their own magic number that represents their FERTILITY ODDS for that month assuming they have sex every 2-3 days without paying attention to timing. For a couple in their early 20's with excellent sperm and perfectly clean Fallopian tubes and with the wife being an overachiever who ovulated not one, but two eggs that month, their fertility odds (FO) that month might be 50%. (By the way, it's not standard to ovulate two eggs in one month, but there are women out there in which a lot of fraternal twins run in their families. These women could potentially ovulate double from time to time.) While this lucky fertile couple have a really high FO, contrast this to her next-door neighbor, who is 39 years old, overweight, with irregular periods, endometriosis and one blocked tube and a husband who smokes 2 packs a day. Their FO is less than 1%.

In general, the FO in a given month for a couple of average fertility is about 20-25%. But remember the concept of averages. The average American woman is 5'4" tall. However it's not uncommon for women to be significantly shorter or taller than that. Likewise, there are some couples who are super fertile and have higher FO above 30% and others who are subfertile with FO of 5%. In general, couples with high FO's don't obsess about basal body temperature, cervical mucus nor ovulation kits, because they don't have time to do that in between all the babies they have. These are couples for whom pregnancy comes to them right away the moment they get lax about contraception. Couples with average FO's may or may not get to the point where they start stressing about ovulation timing, depending on how lucky they are. For example, compare having a FO of 25% and trying to conceive to playing a simple game with a deck of cards in which the rules are as follows. Every cycle, you shuffle the cards and draw one card at the time of ovulation and hide it in an envelope. You don't get to reveal that card until 14 days later. When you finally do get to see it, if it is a heart, then congratulations! You are now pregnant. If it is not a heart, then your period starts. You place the card back and put the deck away until next month. I'm sure many of you can imagine what it is like to play this game. Now, if you have normal fertility with a normal 25% FO, then you play with a normal deck of cards and it's almost for sure that you will eventually draw a heart, most likely before playing this game for six months. Still, even if you are normal, but just unlucky, you COULD possibly go on a cold streak and draw 7 or more cards and still never get a heart. However, in time, the odds will even out and you will eventually get your heart.

So what happens if you end up playing this game for three years and still never draw a heart. Obviously, your first suspicion is that you are not playing with a normal deck. Maybe only 2% of the cards are hearts, meaning you'll have to play this for a lot longer before you finally draw a winner. Worse still, maybe there are no hearts in your deck at all, meaning all this time was a waste and the only way you can get pregnant is with medical treatment. Or what about women who don't ovulate. For them, it's like not getting a chance to draw a card at all!

So, after all this background info, I'll now return to the topic of timing intercourse with one's ovulation. OK, stay with me here. As we have just gone over in great detail, every couple has a specific FO each month. The factors that affect your FO include passive factors for which you don't have instant control (age, weight, whether the tubes are blocked, sperm count, overall wellness) and active factors for which you DO have control, primarily when you have sex.

So let's assume that you and your husband have a 25% FO.

Here are the key points:1. If you have sex every 2-3 days, your odds of pregnancy that month are 25%.2. There is a certain day that you are most fertile. If you actually have sex on that day of peak fertility, you might be able to bump your odds up above your regular FO to maybe 30%. You might realize that if you just have sex every 2 days, you'll probably hit that day of peak fertility half the time anyway, without all the bothersome charting.3. If you DON'T have sex at all in the 4 days leading up to and including your peak day, you drop your FO to 5% that month.4. If you don't have sex in the 6 days leading up to and including your peak day, you drop your FO below 1%.

So how does meticulous timing affect your chances? It depends on how you do it.

METHOD A: Some couples have sex every 2-3 days anyway, but use ovulation timing to make sure they get together on what they believe to be their one peak day. If they are correct about the peak day (and chances are actually good that they are NOT always accurately predicting the perfect peak day despite all the charting and ovulation predictor kits) then they can boost their chances that month from 25% to 30%. If they guess wrong about the peak day, then they are back to their normal 25%.B: Other couples deliberately try to abstain until what they think is their peak day. Wives tell their husbands to stay away and save up their sperm until they are given the green light! In this case, if your prediction methods are accurate, then you have a 30% chance that month. If you guess wrong and are early by one day, you have a 25% chance. BUT, if you guess wrong and are late by 1 day, then you have less than a 1% chance!! Why is this? Because if you have sex only AFTER you ovulate, even if the egg is still viable, the cervical mucus undergoes changes to shut out sperm from coming in. After the egg has already released, you can still get pregnant through insemination, thereby using a catheter to bypass the hostile mucus, but studies show it's almost impossible to get pregnant through natural intercourse if it's done only AFTER the egg has released.

So you see, in scenario A, trying to time things might only help a little at best, while most of the time it doesn't change your odds at all. In scenario B, if your timing is accurate, it might help a little or be the same, but if your timing is inaccurate, you have now disastrously LOWERED your chances.

Therefore the best general strategy is to have sex every 2 days, especially in the week leading up to your time of ovulation.

I'll close by fulfilling my earlier promise to list the instances in which monitoring your ovulation is NOT completely worthless.1. If it relaxes you and lowers your stress to feel like you're doing something. A lot of times, women find great social support from discussing their temperature and charting with other women who are trying to conceive. Anything that lowers stress can contribute to higher FO. It also reassure you about the likelihood that you ARE ovulating. If your monitoring activities clue you in that you're not ovulating, then you will be alerted to seek help before wasting too much time.2. If you are a couple who have sex only once or twice a month and just cannot for whatever reason make it feasible to have sex every 2-3 days, then it WOULD be useful to employ ovulation monitoring to help you focus on the days that really count.

But remember, if ovulation monitoring CAUSES you more stress or if you do it wrong and it causes you to miss your peak day, then it is clearly harmful to your chances.

The woman at the dog park was herself in a job where she was trained to think analytically and scientifically, so she loved learning this detailed information. She joked about how we humans have evolved into a species for whom normal reproduction requires the act of taking temperatures. By this time, our dogs were exhausted. She thanked me profusely and asked for my contact information. She also thanked my dogs for enabling our chance meeting.

By the way, here is a video of my dogs, Brandy and Ixie, engaged in friendly combat. =)

August 26, 2007

I take my responsibility to my patients seriously. In order to give them the best care, I need to have access to specific information about their condition. This is obtained through taking time to discuss detailed questions with them on a regular basis and through direct examination and through the help of lab tests. This type of 1-on-1 care is the best kind. However, the finite number of hours in a give work week limit the number of patients who are able to get this type of special attention from me. In contrast, an unlimited number of people can get helpful information through this site without ever meeting me. The drawback is that without taking into consideration their specific situation, they can infer no individualized advice. In other words, you have to take the information here and make your own decisions. This may sound common sense, but I would hate for someone to misinterpret my words as being strict advice aimed directly towards them and thereby make a decision that might end up being wrong for them! Again, I hope it is common sense that people realize everybody is different and what might be the best advice for 99% of people, might end up being terrible advice for somebody in the remaining 1% because of circumstances that are unique to them.

Please take responsibility for your own fertility plans and do it conjunction with your own physician's recommendations. Meanwhile, you are certainly welcome to benefit from any information that this site can humbly provide.

I am heeding legal advice that in this day and age, it is necessary to put a disclaimer like this on this type of website, so there it is (oh well). =)

August 23, 2007

Polycystic Ovary Syndrome is a condition that affects close to 10% of the women in the world.

Women who suffer from this condition usually have many of the following findings:Infertility - PCOS patients are sometimes able to get pregnant naturally, but many of them will have difficulty.Obesity - PCOS patients generally have greater body mass than women without PCOS. However, it is not univeral. A few PCOS patients have normal or even extra lean body mass. Another general finding is that PCOS patients tend to gain their excess weight around the midsection (as opposed to the thighs or hips).Excess Male Hormones - Women have low levels of male hormones, but women with PCOS have higher levels, leading to the possibility of facial hair, chest hair, acne, male-pattern hair thinning, oily skin and bloating.Irregular or Inconsistent Menses - PCOS patients often do not ovulate every month. Some of them can go a whole year without a single ovulation or period.High Risk of Cardiovascular Disease - Women with PCOS are generally more prone to high blood pressure, high cholesterol, heart attacks, strokes and diabetes.

While there is no cure for PCOS, there are many available helpful interventions that can address the issues of infertility, irregular menses, obesity, excess male hormones and health risks.

In future posts, we'll look at the specific interventions that can help improve the quality of life for women suffering from PCOS.

August 20, 2007

The universal way to create things is to start with the right components and then to assemble them properly. When cooking, the quality of the finished dish depends on the ingredients you use as well as how you put them together. Building a car involves using the right parts and then performing proper assembly.

The same applies to the making of a baby. In a previous post, we learned about the components that are used in making a baby, specifically the maternal DNA packaged into an egg and the paternal DNA packaged into a sperm. The joining together of sperm and egg take place in the woman's body, usually in the Fallopian tubes. If the sperm and egg are both perfect enough to create a perfect embryo and if that embryo properly migrates into the a hospitable uterus, then you will have a perfect baby.

So in order to make a baby, you basically need sperm and egg to come together and for that sperm and that egg to be perfect enough to create a surviving embryo. This leads into the generation of many ideas on how we can improve the odds of pregnancy for infertile couples.

1. You can improve the quality of your sperm and eggs by overall getting healthier. Some ways include getting to the optimal body weight, avoiding tobacco, avoiding environmental toxins, avoiding excess stress, treating any existing medical problems.2. You can improve the chances of the egg and sperm physically coming together. Some ways include intrauterine insemination and IVF.3. You can improve the QUANTITY (and sometimes the quality) of eggs. This is done with ovulation medications.4. You can substitute better sperm and eggs from somebody else, if necessary. This is done with donor sperm or donor eggs.5. You can optimize the final implantation site for the embryos inside the uterus. Some ways include surgically cleaning out any abnormal uterine lesions, hormonally preparing an optimal lining and eliminating any immunological problems.

Looking at things systematically and logically can help us understand the rationale behind the various fertility treatments available.

August 16, 2007

The happiness associated with helping couples have babies is one obvious great aspect of my particular field of work. Another great thing that is often overlooked is the chance to always keep learning. Working in infertility does not get stale because the pool of knowledge out there is always changing. In fact, the rate at which new discoveries are being made has continued to dramatically change this field every few years. The success rate of treatment is increasing. The available options for patients are increasing as well. I love the fact that the more I choose to increase my knowledge, the better job I can do for my patients. One way of learning is just through the experience of actually taking care of patients. A second way to supplement that learning is by reading. A third way is what I did earlier this week.

Two nights ago I had dinner at Derek's Bistro in Pasadena with eight other reproductive endocrinologists and two embryologists along with some other people who work in the field of infertility. The atmosphere was relaxed and casual. The food was good.

This was our second Journal Club meeting. Assembled in the room were a group of us who collectively were responsible for well over 1000 IVF cycles in the past year. We had all taken time to gather together for the purpose of exchanging our knowledge. I'm not exactly sure how this started, but the others keep telling me that it was originally my idea. I had once mentioned to the other doctors how nice it would be if we could get together in a non-academic unstructured setting and just shoot the breeze, sharing our own tips and pearls of wisdom gleaned from our own professional experiences.The first meeting several months ago was a great reminder of the art of medicine. While we did agree on many aspects of management, what was more striking was the great degree of disagreement. For example, different reproductive endocrinologists present at the meeting, all with a long solid track record of successfully helping patients get pregnant threw out very different opinions on controversies such as the effect of intramural fibroids on IVF success, the right indications for prescribing metformin, the importance of weight loss in obese infertility patients. The debates were fun and friendly.

This week's meeting was more structured as one of the other RE's did a great job finding three recent journal articles to discuss. There was still plenty of lively disagreement. I am always open-minded and hungry to learn alternative ways to do things. In future posts, I will share specific revelations that I learned at these meetings that might affect the specific strategies I use in my practice to help my patients.

August 13, 2007

Ovulation is the rupturing of a follicle with subsequent release of an egg.

Women are born with 1-2 million eggs. These lay dormant in the ovaries wrapped in a layer of cells. A FOLLICLE is the name given to an egg surrounded by the layer of cells (known as granulosa cells).

Each month, out of the entire supply of follicles, a small group of them (known as the recruited cohort) begin to grow. Most of the time, under natural conditions, only one of the follicles grows to the mature state. This is called the dominant follicle. The rest of the follicles that month only grow partially and are wasted, lost forever. Under conditions when a woman takes fertility drugs, many more of the original group of follicles can be rescued so that they, too, have a chance to initiate a pregnancy.

From many lectures to my medical students, one analogy that seems to help clarify is to envision the follicle as a slowly-growing "water balloon" which has a tiny grain of sand inside (this sand represents the egg). When the follicle reaches about 18-20mm in diameter and a special hormonal signal, called the LH surge, is sent to it, it will undergo biochemical changes that eventually result in the popping of the follicle and the release of the egg. This special hormonal signal is what those urinary ovulation kits are designed to detect.

August 10, 2007

It’s
human nature that when things are not happening the way we want, we try to take
actions in an attempt to change things. Some of these actions make an actual
difference. But the truth is that many actions may not significantly help us
achieve our goals, but do serve a purpose of calming us by allowing us to
pretend it’s making a difference.

For example, a man who is depressed because he hates his low-paying job might
regain a sense of hope by sending out resumes and going on interviews. Alternatively,
he might instead seek hope by purchasing a lottery ticket each week and
fantasize about how winning might rescue him from his current situation. The first approach is likely to make a difference eventually. The second approach is almost impossible to make a difference.

There are many things infertile couples can do to help themselves get pregnant.
Some couples only need be patient and wait for pregnancy to eventually happen.
Others will require medical assistance. For couples who do not yet wish to take
advantage of modern medical advancements, the most popular way for them to
take action is to meticulously obsess about the timing of intercourse to try
and coincide with supposed peak fertility times. But is this the best strategy?

Actually, for most couples, it’s NOT. For them, compulsively timing intercourse
with the help of calendars, basal body temperature, cervical mucus awareness or
ovulation detection kits serves more to placate them psychologically than to
actually make a difference between pregnancy and no pregnancy. In some cases, being so obsessed about strict timing can even LOWER some couples' chances of conceiving by adding extra stress and decreasing their frequency of intercourse. Why is this true? The secret is as follows: Because your odds of conceiving on your peak day are not much different from your odds of conceiving on the day before that. I will elaborate on this more in future posts. Meanwhile, keep in mind the best strategy for most couples is to randomly get together every 1-3 days.

August 06, 2007

I was catching up on reading the July 2007 issue of the journal HUMAN REPRODUCTION during lunch and I found an interesting study out of Denmark that looked at the possibility of an increase in autism among babies born from fertility treatment. To the researchers' surprise, they discovered an actual DECREASE of autism risk in babies born from different fertility treatments (including hormonal treatment and technical treatment) as compared to babies conceived naturally.

To better understand the implications of these findings, let's look at how this data was obtained. The researchers started by reviewing the medical records of 461 babies born in Denmark between 1990-1999 who were later officially diagnosed with infantile autism. Next, they found 461 other non-autistic babies who matched the autistic ones in terms of gender, year of birth and county of birth. They then compared these two groups to look for any differences in the number of children who had been conceived from fertility treatment.

Of the babies in the autistic group 2.3% of them had been born from fertility treatment. Of the babies in the non-autistic group, 5.4% where born from fertility treatment. This was statistically significant and showed a lower risk of autism in the children who were conceived with some type of fertility treatment in comparison to those conceived naturally.

There could be some interesting factors that affect this. For example, one can imagine that women who are undergoing infertility treatment tend to be watched more closely by doctors and may also tend to be better about taking vitamins. Either of these alone could be the possible reason that the fertility babies did better in terms of avoiding autism. This initial study is promising and future research will serve to investigate this further.

August 04, 2007

Fertility drugs are given to help women who don't ovulate perfectly on their own. They are also given to women who already ovulate to help them super-ovulate, meaning increase the number of eggs released (better quantity) and to improve the chances that the eggs will successfully become a baby (better quality).

The two main classes of ovulation medications work on the principle of improving FSH activity. FSH (Follicle-Stimulating Hormone) is a natural substance produced in the brain (actually, from the pituitary gland) which communicates with the ovaries to persuade the ovaries to develop and mature an egg or many eggs.

With the goal being to increase the strength of FSH that is talking to the ovaries, there are two ways to do it. We can either help people make more FSH on their own or to actually give them FSH. This is like helping someone who doesn't have enough money by either giving them tips on how to make more money or by just giving them a large amount of money. One way is gentler and easier, the other way is more direct and much more powerful.

CLOMIPHENE CITRATE: Taken by mouth in pill form. This is a gentler medication that can help a woman produce more FSH on her own. Brand names in the US include Clomid and Serophene.

INJECTABLE GONADOTROPINS: These are actual injectable forms of purified FSH. Brand names in the US include Bravelle, Follistim, Gonal-F, Menopur, Pergonal and Repronex.

hCG: hCG comes in an injectable form. While the above two classes of drugs work to help the eggs develop and grow, hCG does something entirely different. It works to trigger the follicles to burst (ovulate) and release their eggs. So the sequence is take clomphene citrate or injectable gonadotropins first. And then when they have done their job, take hCG to finish the ovulation process.

Watch for more detailed information regarding these drugs in future posts.

August 02, 2007

When a husband and wife make the decision to actively get professional help in their quest for a baby, the first step is the initial consultation. This is much more than just an evaluation visit. It is the all-important first encounter between patient and doctor and it is sets the tone for the professional relationship.

Many of my new patients have already had some infertility treatment elsewhere. Based on their stories, here are some are some common things that they sometimes felt were missing.

Ask yourself if the following criteria have been met in your own first visit:

YOU SHOULD HAVE GAINED AN OVERALL UNDERSTANDING OF YOUR SITUATION. A good first consultation is not a one-way interaction in which the doctor asks all the questions. It should also be an educational session where you are educated and your questions are answered. Ideally, your doctor should be able to give you an overall idea of how serious your condition is and how favorable your chances of getting pregnant are, based on the information available so far.

YOU SHOULD HAVE BEEN GIVEN A CLEAR IMMEDIATE PLAN AND SOME IDEA OF THE LONG TERM CONTINGENCY PLANS. At the end of your consultation, you should know what the next step is, whether it be to get some tests or to choose a particular treatment. If there is only one test planned, you might even get an idea of where to go from there after the tests are back. For example, if this test result is A, then we will do this. If B, then we will do this. If there are multiple tests, then it is best to wait until the results are back and then formulating the next step, rather than try to go through all the permutations of possible results.

YOU SHOULD FEEL CONFIDENT THAT YOUR DOCTOR IS KNOWLEDGEABLE. If you have an uneasy feeling about your doctor's level of expertise, it is your right to ask for further clarification on their thought process in the recommendations they have made for you. It is also reasonable to ask your doctors regarding their training and career experience. No matter how many diplomas, years of practice and board certifications they have, you are still the ultimate judge of whether or not your feel comfortable with this person as your doctor.

YOU SHOULD FEEL CONFIDENT THAT YOUR DOCTOR HAS YOUR BEST INTERESTS AT HEART. One common feedback from patients is that their previous doctors seemed very pushy about selling them on IVF and deflected any questions about other options. There is a difference between a recommendation of IVF because it is the best option for a given couple's particular situation vs a universal push towards IVF in order to boost the practice's IVF volume. You are entitled to an all-important discussion of all your options as well as the pluses and minuses of each choice. Once again, you are the ultimate judge of whether you feel comfortable trusting the doctor's recommendations or not.

YOU SHOULD HAVE HAD THE CHANCE TO SHARE ALL THE INFORMATION THAT YOU FEEL MIGHT BE RELEVANT. Your should be satisfied that your doctor made a thorough attempt to investigate the things in your life that might have an effect on your fertility, including the factors that contribute to your stress level. Any questions, even minor ones, such as how much soda you drink or how much you sleep, are permissible to discuss if you are concerned about their relevance.

YOU SHOULD FEEL SATISFIED WITH THE TIME AND PACE OF THE VISIT AND YOU SHOULD HAVE FELT UNRUSHED. Ideally, all your visits will be satisfying and unrushed. However, in reality, for some of your follow-up visits, when you are just having an ultrasound or blood tests done, it won't be feasible to have an in-depth discussion with your doctor each time. The initial consultation visit is different. I don't think it is unreasonable to spend one to one and a half hours during the first visit. From time to time, it might be necessary to have reconsultation visits.YOU SHOULD HAVE GAINED CONFIDENCE ABOUT THE OFFICE TEAM. Don't forget to pay attention to the level of service and care given to you by the rest of the office staff and medical team. The doctor is not going to single-handedly conduct all your interactions. Even before you see the doctor, you will have a chance to form your own opinion on how promptly and courteously you were treated so far, both on the phone and in person.

If you care that one of the above points is missing from your interaction with your doctor, it's not too late to fix it. Next time, bring up the topic, so your doctor can have a chance to make things right. Your time is too valuable to waste.

July 30, 2007

A semen analysis is a test to evaluate the husband's sperm. It is one of the least expensive, least invasive tests in the standard fertility evaluation. To perform the test, the husband is asked to abstain for at least two days, preferably three, and no more than seven days. He is then instructed to ejaculate into a sterile cup and bring the sample to the office within one hour.

Upon receipt of the sample, the first thing done in the laboratory is to look at it and describe anything unusual about its color or appearance. Next, the sample is measured for its volume. Finally, a drop of it is placed into a special counting chamber, such as the Makler chamber, which is what we use in our office.

By counting how many sperm fall into the squares of a precisely calibrated grid and by distinguishing the moving sperm from the non-moving sperm, a sperm count and motility are calculated.

The basic two features evaluated are the sperm count and the sperm motility. The count refers to how many sperm there and the motility refers to how many of them are moving.

There are also more detailed features that can be determined about the sperm, such as the morphology and the DNA integrity.

July 26, 2007

Prior to 1978, for many couples with infertility, the chance of cure was as bad as the chance of cure for many terminal illnesses such as some types of cancer, meaning there was almost nothing that could be done. These couples either successfully adopted or they proceeded to have a childless life.

The discovery and development of In-Vitro-Fertilization (IVF) changed that tremendously. There are three types of problems that contribute to infertility – problems with the wife’s eggs, problems with the husband’s sperm and problems with the “plumbing” (the anatomic pathway which allows the sperm and egg to come together and nourish a thriving baby). In medical terms, this refers to the woman’s fallopian tubes, uterus and cervix.

IVF involves taking the sperm and egg and bringing them together in a laboratory for a few days before being put back into the mother’s body as an intact embryo. The rest of the pregnancy journey takes place just as it always has in nature, inside the mother’s womb. Initially, IVF was thought of as just a way to solve the plumbing problems. Instead of relying on a sperm and an egg to come together inside the body under natural conditions, women with scarred or missing tubes could still have a baby by having the sperm and egg introduced to each other outside the body under ideal laboratory conditions. Over time, IVF has evolved to help couples with severe sperm problems and even couples with significant egg issues. Couples with extremely severe egg issues can not be helped through IVF, unless they are willing to enlist the help of an egg donor. While IVF is still not 100% in its usefulness to infertile couples, it has come a long way.

Rather than be some space-age oddity, IVF has become an everyday household word. As of 2006, over THREE MILLION IVF BABIES have been born. In fact, over 1% of the healthy babies born in the US today arrive as a result of IVF. In certain other countries, that ratio is higher than 3%. As with any new scientific advancement, there are questions as to long term consequences. The issue of future health in IVF babies has successfully breached new hurdles as each generation of IVF babies successfully finishes infancy, childhood and now, early adulthood without any major surprises. As time has passed, we have reached the moment when the first generation of IVF babies are starting to have their own normal babies and the majority of them appear to be doing so naturally, without the need for any infertility treatment.

Today, there are still some people who promote the extreme view that all scientifically advanced ways of assisting reproduction, including In-Vitro-Fertilization, should be banned. While it is true that as mankind discovers more advances that push the limits of nature, such as cloning and genetic selection, we need to constantly evaluate the differences between what we CAN do vs. what we SHOULD do. However, to argue for elimination of IVF would unfairly deprive many infertile couples of the option of having a baby. IVF is now a proven effective way to help most couples exercise their privilege (or their RIGHT) to be happy parents.

July 23, 2007

As you seek to learn ways to help you have a baby, you will run into a lot of scientific details. Knowing the general concept of how a healthy baby is brought to life will help you better understand these details.

Advanced organisms, including us human beings, reproduce by SEXUAL REPRODUCTION. In contrast, simpler organisms, such as bacteria and amoebae reproduce by ASEXUAL REPRODUCTION. Imagine if we reproduced asexually, just like an amoeba. Then, when it came time to make a baby, a piece of ourselves would pinch off and become another organism identical to ourselves. However, that is not the case. We reproduce sexually, meaning it requires two separate organisms (father and mother) to each contribute half of their genetic influence. These come together to make a new person who has a 50/50 combination of the genetics of the two parents. One marvelous advantage of our reproducing this way is the ability to generate nearly infinite diversity. It's the reason that all of us (except for identical twins) are genetically unique.

All babies, including ourselves way back at one time, start out as an embryo. What makes each embryo different is the special genetic information within the DNA. The unique information encoded in our DNA is what regulates our physical features such as eye color, potential height or vulnerability to diabetes.

When a husband and wife set out to create a baby, they each contribute half of their genetic information to create a new person. Each time they do this, they send out a random combination comprising half of the billion bits of genetic information in their DNA. This is the reason that a man and woman can produce a different child each time, rather than having children who are exact replicas of each other.

What are gametes? A human being is composed of many cells. Estimates range from 10 trillion (10 million million) to 100 trillion cells per person. Each of the cells in our bodies contains the same full set of DNA with the exception of sperm cells and egg cells. These are collectively known as gametes and are special in that they only contain half the DNA of other regular cells. The reason they contain half is so that one sperm and one egg can add together to make a fertilized embryo that has a normal full set (half plus half) of genes.

As you and your spouse try to conceive, it may help your understanding to remind yourselves that you are essentially attempting to combine your genetic information by way of your sperm and your eggs. Anything short of one perfect sperm uniting with one perfect egg will fail to produce a healthy baby.

In future posts, we'll learn the important differences between how sperm and eggs function to affect your odds of getting pregnant.

July 19, 2007

Judging from the questions I'm getting, the greatest fear still for many of you is that month after month is being wasted waiting for pregnancy when in reality, it's just not going to happen naturally for some reason. Most average couples can expect a normal 20% chance each month to get pregnant. If you are in this group, it is smart for you to just be patient, because pregnancy will happen without any special action on your part, usually within six months. Even if you are subfertile and only have a 10% chance each month, you still can expect to eventually conceive on your own. It just might take a year or so. But if you only have a 0-1% each month, then all you're doing by putting off getting help is just wasting time as your reproductive potential is gradually depleted.

The moment you make your decision that you would like to get pregnant, there are three questions to ask yourselves right away.1. Am I not releasing an egg each month?2. Is there adequate sperm?3. Is there any physical barrier to the sperm and egg meeting properly?

The answer to the first question is one you can easily figure out yourself in many cases. If you are not getting your period at least ten times per year (no less frequent than every 35 days), then you are not ovulating as often as you should and therefore, time is being wasted during your reproductive years. It's wise to get help sooner rather than later.

The second question can only be answered by doing a semen analysis. There is no way to know the truth about a man's sperm just by looking at him nor by analyzing his general health. Granted, if he has fathered several pregnancies in the past, and nothing drastic has happened to his health since then, most likely, he does not have any severe sperm problem. A semen analysis can be done fairly easily for under $150 and is a very basic test to start with.

The third question can best be answered with a test called a HysteroSalpingoGram or HSG. This is a test where a special liquid is gently introduced into the uterus and images are taken to see where the liquid flows. This can detect if you have a polyp or fibroid tumor in the uterus that is blocking your implantation. It can also show if your Fallopian tubes are blocked or not. You should be suspicious that you might have these problems if you have had previous gynecological surgery, previous pelvic infections, very painful periods or especially heavy ones. Compared with a semen analysis, this test is more costly and more inconvenient to do, but can be obtained usually for under $800.

So how do you avoid wasting time?

Here is one good approach:1. Begin by understanding the stages that couples go through in their desire to have a baby and figure out where you are.2. Stop all contraception and maintain a patter of having sex every 1-3 days (preferably every 1-2).3. If you have regular periods and are under 40 years old and do not suspect a physical barrier to pregnancy, then set yourself a deadline of 4 months, 8 months or 12 months depending on your age and personal sense of urgency.4. If your deadline arrives and you're still not pregnant, make a decision regarding which you would rather do: semen analysis, HSG or consult a fertility specialist. At the very least, do a semen analysis. It's cheap and fairly convenient (the sample can be produced at home and does NOT have to be produced in the lab or doctor's office). If the testing is normal, set a new shorter deadline of 4 more months.5. If still not pregnant by then, choose another action that you did not choose before. Most people would choose the semen analysis the first time and then the HSG the second time. Both these tests can be ordered by your primary care physician or by your OB/Gyn.6. If both these tests are normal, but you are still not getting pregnant another four months later, it's time to see a reproductive endocrinologist.

By following these simple steps, you can avoid unnecessarily wasting time. Best of luck!

July 17, 2007

I just returned from the 20th Annual UCLA In-Vitro Fertilization review course held in Santa Barbara each year, where dozens of reproductive endocrinologists from around the world convene to review the latest on IVF.

During the drive there, I was rewarded with a soothing view of the Pacific Ocean on my left, as I looked forward to spending time at the Four Seasons Biltmore. I like these meetings for reasons besides getting to improve my knowledge about topics ranging from the optimal ovarian stimulation protocols, embryo transfer techiniques and patient management strategies. I like them for the chance to catch up with old friends and colleagues in the field from around the world. There's a lot to be learned, not only from the lectures, but also from trading tips and stories at night around the dinner table. I first attended this particular meeting when I was a UCLA Reproductive Endocrinology fellow, but find there's always plenty of new things to learn each year. It's helpful to see what other people are doing in their practices to help their patients get pregnant, meanwhile being respectful that there are many ways to accomplish the same goals.

Also present at these meetings are reps from the major companies that manufacture IVF equipment, embryo culture media and the medications that we use in our work.

The highlight for me this year came when I found myself in the auditorium watching a slide on the large screen showing a family with mom, dad and two lovely daughters in their late teens / early 20's. About 20 years ago at UCLA, one of the earlier IVF cases involved an egg retrieval done by ultrasound guidance through the bladder. One of the embryos that was created became the older daughter and another embryo was frozen and then transferred a few years later to give birth to the second daughter. The speaker at the lectern was Dr. David Meldrum, the physician who performed those procedures. He had just got done giving an excellent talk about the history of IVF. Afterwards, to the delight of the audience, one of the two daughters in the slide came on stage and gave him a plaque and a warm thank-you for helping bring her into this world. It was a touching reminder how all our work with sperm, eggs and catheters gives rise to very real babies and families!

This year, as always, I came back with a few new ideas to incorporate into my practice. I didn't bring my camera this time, but I hope to take pictures when I go to the next big conference, the annual meeting of the American Society for Reproductive Medicine, which will be in Washington DC this October.

July 13, 2007

This question is one of the most commonly asked by women who have yet to have a baby. If you are looking for just a rigid definition, by one commonly accepted set of criteria, if you have been wanting to have a baby (not practicing contraception) for over a year, but still are not pregnant, then you can be considered infertile. However, a more useful way of thinking is, rather than focus solely on labels and getting caught up in rigid definitions, to instead step back and look at the big picture and ask ourselves some more practical questions.

Question 1. Is it reasonably possible that I will be able to get pregnant and give birth to a live healthy baby?

Question 2. If so, what is/are the next step(s) that I need to take in order to make it more likely to happen?

Just as for any goal in life, it is sometimes best to think it terms of actions and decisions. Keep this in mind if you find yourself in the situation of wondering if you're infertile. The correct questions to ask are whether or not you are reasonably able to have a baby, and if so, what should you do next?

Anyway, in order to specifically answer these questions, it is necessary to know more information about you and your partner. The three items of specific information that would be especially important would be the likely condition of your eggs (as based on age and other factors), the condition of your uterus and Fallopian tubes and the status of your partner's sperm.

July 09, 2007

The uterus is the female organ which serves as the baby's home during a pregnancy. It begins as a muscular organ about the size of an orange and slowly grows during pregnancy to be large enough to accommodate a full term baby.

The lowest part of the uterus is the door by which the baby eventually exits. This is know as the cervix. There are also two openings at the top of the uterus that lead to the right and left Fallopian tubes. After a sperm fertilizes an egg, an embryo is formed which travels from the tubes into the uterus.

Every month, there is growth of an inner lining of the uterus. This is known as the endometrial lining. If a healthy embryo enters the uterus from the fallopian tubes, then the lining remains in place for the duration of the pregnancy and serves to nourish the baby. If no healthy embryos shows up that month, then the lining is shed as a menstrual period.

One of the most common ways in which uterine abnormalities contribute to infertility occurs when there are fibroid tumors inside the uterus. The fibroid can act the same way that an IUD contraceptive device works in preventing successful implantation. Fibroids that are inside the cavity of the uterus should be removed in infertile patients before proceeding with other types of treatment.

Gratitude extended to Dr. Davide Brunelli for his unique digitally-rendered images of the uterus.

July 06, 2007

When it comes to having difficulty getting pregnant, you have a choice. You can get help or keep trying to do it on your own. Most of the time, it's easy. In fact, over 80% of couples are able to get pregnant on their own within six months to one year. If you are in the other 20% and have gone over a year without success, it's time to make a decision. Here are FOUR warning signs that you need to seek professional help.

1. AGE: If you are over 35, you are at increased risk for miscarriage, pregnancy complications, birth defects and the possibility of never having a child. Getting help sooner than later is strongly advised. As a rule of thumb, if you are over 35 and nothing has happened after one year, get help. If you are over 38 and nothing has happened after six months, get help. Couples over 41 who haven't even started trying might benefit from a single pre-conception consultation visit to help plan their fertility strategy. Note that these guidelines refer to the age of the wife.

2. DURATION: If it's been over two years without birth control and you're still not pregnant, it's time to get help, because most likely something is wrong. Exceptions include situations where there is a clear excuse such as job assignments or military assignments so that husband and wife are geographically separated the majority of the time. Please note that the two-year limit mentioned is a "red-alert" level for taking action. You are well-advised to seek help even if it's only been one year.

3. OBVIOUS SUSPICION OF A PROBLEM: Some people already anticipate trouble conceiving even before they start trying. These would include couples in which the wife fails to have periods every month, couples where at least one partner has significant medical problems or situations where the wife has had serious gynecological problems in the past. It makes sense to get help quickly in these situations, even if hasn't been a full year yet.

4. URGENCY AND PRIORITY: On one extreme, if you are very willing to accept never having children at all, then you can certainly continue trying on your own without any time limit. If you DO get pregnant on your own, it will be a great blessing. If you don't, then you are able to accept it. On the other extreme, if the thought of having a baby is the #1 priority consuming your every waking moment and is seriously hindering you from enjoying life, then you owe it to yourself to at least discuss things with a professional immediately.

REMEMBER: Always have a plan! Even if that plan consists of trying on your own for 12 months, at least you have a safety net for when you will be triggered to move to the next step and seek treatment. If you are not pregnant yet and want to be, make sure to set yourself a deadline so that if you're still not pregnant by that time, you will take action and do something! This is the only way to reassure that you don't let time pass by before it's too late.

July 02, 2007

You would like to have a baby and would like to know where to begin. Before we discuss what to do, let's review the big picture of the stages couples go through with regards to having a baby.

The earliest stage that couples pass through is the "DON'T WANT BABY YET"
stage. Often, this is during the first months of marriage when the
priorities of getting adjusted to married life, setting career goals or
traveling take precedence over any desire of starting a family yet.
This is a time when the couple is fairly meticulous about
contraception, either with birth-control pills or condoms or even just
deliberately timing to avoid the fertile periods. All these actions are
taken because the couple strongly prefer not to get pregnant yet.

Next comes the "IF IT HAPPENS, IT HAPPENS"
stage. By this time, husband and wife feel ready for a baby if they
should be so blessed, but still are in no hurry. So unlike in the
previous stage, all effective forms of birth control are cast away and
the couple enter a very carefree period where they are happy if they
get pregnant and happy if they don't. It is in this very time that over
80% of couples WILL get pregnant naturally within a year, many of them
within six months.

Next is the "GETTING JUST A LITTLE WORRIED"
stage. As month after month passes by, there is a
rise in anxiety as pregnancy fails to arrive. There is still no drive
to do anything active, but this is a time characterized by casual
surfing of the internet for information or possibly consulting some
books. The topic eventually comes up during conversation between
husband and wife, with the two of them agreeing to just give it a
little more time. Many couples will dabble with meditation,
acupuncture, fertility good-luck-charms, nutritional supplements,
changing from briefs to boxers, lying upside-down after sex, using
ovulation kits to time things and various other actions without
necessarily asking for help from a physician. Fortunately, for many
couples, the stork will finally arrive during this time and they might
even credit their success to the various interventions they did and
share this advice with their infertile friends, when in reality, it was
just a matter of patience and time.

Finally, about 15% of American couples will reach the "DON'T WANT TO WAIT ANY MORE"stage and they will seek professional help. In future posts, we'll discuss two important questions.